One form to get support with Orilissa^® Complete

This information is for informational purposes only and is not intended to provide reimbursement or legal advice. The information presented here does not guarantee payment or coverage.

^*The ORILISSA free trial provides a single 28-day trial supply of ORILISSA at no cost to new patients residing in the United States with a valid prescription for an FDA-approved indication of ORILISSA and who enroll in Orilissa Complete. The trial is intended solely to allow new patients not currently taking ORILISSA to determine with their healthcare provider whether ORILISSA is right for them. There is no obligation to continue use of ORILISSA after the trial has concluded and this program does not guarantee insurance coverage. Eligible patients are limited to one 28-day trial supply and may not re-enroll. The ORILISSA trial supply will be dispensed only through an AbbVie-authorized pharmacy to the patient’s home address and may not be sold or further distributed. No claims for payment may be submitted to any third party insurance plan for product dispensed by program. AbbVie reserves the right to change or discontinue the trial at any time without notice. The trial is not health insurance and is not a discount, coupon, rebate or financial assistance program. Limitations may apply.

^†Program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be eligible to participate in program. Available to patients between the ages of 18-63 with commercial prescription insurance coverage who meet eligibility criteria. Eligibility: Patients must be diagnosed with endometriosis, have a valid prescription for ORILISSA, and participate in a commercial insurance plan that has denied or not yet made a formulary decision for ORILISSA. Once the patient’s insurance plan has made a formulary decision and established a process for reviewing coverage requests for ORILISSA, continued eligibility for the program requires the submission of a Prior Authorization prior to the next scheduled dose and appeal of the coverage denial within 180 days. Program provides ORILISSA at no charge to patients for up to 2 years or until they receive insurance coverage approval, whichever occurs earlier. Offer subject to change or discontinuance without notice. This is not health insurance, and program does not guarantee insurance coverage.

^‡Terms and Conditions apply. This benefit covers ORILISSA. Eligibility: Available to patients with commercial prescription insurance coverage for ORILISSA who meet eligibility criteria. Copay assistance program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to use the Orilissa Complete Savings Card and patient must call Orilissa Complete at 1-800-ORILISSA (1-800-674-5477) and stop use of the copay card. Patients residing in or receiving treatment in certain states may not be eligible. Patients may not seek reimbursement for value received from Orilissa Complete including the copay card from any third-party payers. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This is not health insurance.